shows sample sizes and summary statistics for selected demographics, health status measures, and medical insurance coverage of various types (or no coverage), as well as percentages of men who used any health care, and for those who did, percentages who used different categories of care. In either age group, rural men had lower incomes and less education, and were less likely to be nonwhite or Hispanic but more likely to be married currently, than urban men. Whether they used the VA or not, veterans were less likely than nonveterans to be Hispanic, and more likely to have at least a high school education, though this difference was greater among older men. Veterans who did not use the VA were more likely than other men to be married and white and less likely to be poor. Among men younger than 65 years, veterans tended to be older than nonveterans.
Sample Sizes, Demographics, Health Status, Insurance Coverage, and Use of Any Health Care for Men in MEPS Samples in Any of Nine Years, 1996–2004
Veterans who used VA care were more likely than other veterans or nonveterans to rate their physical or mental health unfavorably and to have multiple comorbidities. Regardless of age group or veteran–VA user status, rural men averaged roughly as many comorbidities as urban men, but when urban–rural differences in health ratings appeared, rural residents were consistently more likely to rate their physical or mental health poorly. Rural VA users younger than 65 years were considerably more likely than other men their age to report fair or poor physical health. Among men older than 65 years, however, VA users were no more likely than nonveterans to rate their health unfavorably, though they did have more comorbidities. In either age group, veterans who did not use the VA were less likely than other men to rate their health unfavorably, though their comorbidity rates were comparable to those of nonveterans.
Nearly all older men used some health care, as did about three in four younger nonveterans or veterans not in VA care. Veterans in VA care were more likely than other health care consumers to use each major category of service, but less likely to have commercial health insurance, especially if they were rural residents. Most men 65 years or older had Medicare, but few elderly veterans had Medicaid, less often than nonveterans. Among men younger than 65 years, VA users were most likely to have Medicare or Medicaid (due to disability) or to be uninsured; nearly one in five rural VA users was uninsured throughout the year. Urban–rural differences in utilization were small and inconsistent, regardless of service category or age group. Consequently, the VA provided care to veterans who were sicker and less financially secure than other health care–using men, while veterans not in VA care appear to have had even better health and finances than nonveterans. Rural residents, particularly men younger than 65 years, were at a disadvantage socioeconomically, with respect to insurance coverage, and in reported health.
In analyzing health care expenditures, we controlled for the demographic, health status, and insurance coverage variables in statistically. Most covariates were binary, except for age, annual income, and number of Clinical Classification Categories (comorbidities); we log-transformed the latter two to reduce skewness. Using data only for those men who had any medical care during the year, we calculated mean expenditures and performed regression analyses for each age group separately, assessing group and residence effects, and their interaction.
shows mean adjusted annual medical expenditures (with standard errors) for men who used any health care, overall and broken down by each major component of care and payment source. Each care category or payment source average also is represented as a percentage of the average total expenditures for the column. Men enrolled in VA care cost substantially more overall than other men who used health care: VA users' averages were about $1,200–2,900 higher, depending on age group and residence. Among men younger than 65 years, urban–rural differences in total expenditures were small for nonveterans and veterans not in VA care, but of veterans who used the VA for any care, urban men averaged about $1,100 more in total annual expenditures than rural men. Among men 65 years or older, rural VA users had the highest average total expenditures, about $250 more than for urban VA users. Regressions using log-transformed expenditures confirmed these differences, revealing significant main effects for veteran–VA user status (p<.0001 for either younger or older men) and its interaction with urban–rural residence (p<.05 for younger men; p<.01 for older men; means in any two cells also can be compared by dividing their difference by the square root of the sum of their squared standard errors, and treating the ratio as a z score).
Average (with SE) Annual Population-Weighted Medical Expenditures (Adjusted for Demographic, Health Status, and Insurance Coverage Covariates, with SE Accounting for Survey Design) for Men Who Used Any Health Care during a Survey Year
Within each care category and age group, average expenditures consistently were higher for VA enrollees than other men (all at p<.0001 or p<.001), but differences varied considerably in magnitude: Among men younger than 65 years, average expenditures in most categories were nearly twice as high for VA users as other men, but their prescription expenditures averaged only slightly higher. Urban VA users averaged the highest expenditures in any category, particularly for inpatient care, while rural VA users relied less on inpatient care and more on other care categories. Among men 65 years or older, however, VA users had higher average expenditures, but they differed less sharply from other men, regardless of care category. For older men generally, roughly half of all expenditures went to inpatient and other hospital-based care, and the rest were evenly distributed among office-based care, other health care, and pharmacy services.
The biggest payer for men younger than 65 years was private insurance. Unexpectedly, urban VA users had the highest average private insurance expenditures (regression yielded an insignificant veteran–VA user by residence interaction but a significant urban–rural main effect, p<.001). The next biggest payer for younger urban or rural VA users was the VA; nevertheless, the VA's average portion of overall expenditures was roughly 25–30 percent, thus VA users obtained 70–75 percent of their care outside the VA system. They also averaged paying as much out of pocket as other men under 65 years. Compared with urban VA users, rural users relied more heavily on the VA and Medicare and less on private insurance or other sources to pay for their health care.
For men 65 years or older, Medicare paid the most for care, and the average it paid for rural VA users was more than $500 higher than for other men (regression yielded an insignificant interaction but a significant urban–rural main effect, p<.01). Private insurance and out of pocket payments also were substantial, combining to account for more than 25 percent of average total expenditures. Older VA users got only about one-sixth of their medical care from the VA, so that the proportions of their care paid by Medicare, private insurance, and self/family were only slightly lower than for other men.
In summary, average medical expenditures were higher for older men, VA users, and rural men, but among VA users younger than 65 years, expenditures for rural veterans were substantially lower than for urban users. Urban–rural differences varied considerably across care categories. Medicare paid most for, and private insurance and self/family contributed substantially to, the medical care of older men, including VA users. Private insurance paid most for the care of younger men, including VA users, although younger VA users living rurally received substantially less care through private insurance than urban users. Average VA expenditures accounted for less than one-quarter of VA users' average medical expenses overall.
VA's portion of its users' health care expenditures might appear low because costs are averaged across all users, including those who used VA care minimally, such as for pharmacy services only. Roughly half of the VA users in MEPS used at least $1,000 in VA care, so we compared them with those who used less; mean adjusted expenditures (with standard errors) are listed in . Even the higher users of VA care used non-VA care extensively: Among those younger than 65, higher VA users had total expenditures averaging two to three times those of lower users, and roughly one-third of their expenditures were for non-VA care. Whether they used much VA care, urban veterans still obtained substantially more care. Among men 65 years or older, who were heavier users of VA care, rural residents used more inpatient care while urban residents consumed more of the other categories of care; regardless of residence, they received, on average, only about two-fifths of their care from the VA but got another one-third through Medicare. In short, many veterans who use VA care extensively also use a great deal of non-VA care.
Average (with SE) Annual Population-Weighted and Adjusted Medical Expenditures for Men Who Used Any VA Health Care, Comparing Those Who Used <$1,000 of VA Care in a Year with Those Who Used $1,000 of VA Care or More